Citation Nr: 22013945 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 18-50 843 DATE: March 11, 2022 ORDER Entitlement to additional compensation for Al. C. beyond February 1, 2008 as a dependent of the Veteran is denied. Entitlement to an effective date prior to June 15, 2011 for the award of service connection for respiratory problems with unspecified dyspnea is denied. An initial disability rating of 30 percent, but no higher, for respiratory problems with unspecified dyspnea is granted. REMANDED Entitlement to service connection for a heart condition, to include as due to service-connected major depressive disorder (MDD) and/or respiratory problems with unspecified dyspnea, is remanded. Entitlement to a disability rating greater than 30 percent prior to November 10, 2015, and greater than 50 percent thereafter, for MDD is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Since July 1999, the Veteran has been in receipt of at least a combined 30 percent rating for his service-connected disabilities. Al. C. was the Veteran's stepchild, and the record does not contain evidence that the Veteran adopted her or is in fact her biological father. On January 31, 2008, the Veteran divorced his first spouse, and Al. C.'s biological mother, S. Due to the Veteran's divorce from S., Al. C.'s eligibility to be considered as the Veteran's dependent child was terminated. 2. In July 2003, a Department of Veterans Affairs (VA) Regional Office (RO) issued a rating decision denying entitlement to service connection for a respiratory condition. The Veteran did not appeal this decision or submit any new and material evidence concerning a respiratory condition within one year of notification. Thus, the July 2003 rating decision became final. On June 15, 2011, VA received a formal claim from the Veteran seeking to reopen the previously denied issue of service connection for a respiratory condition. Prior to June 15, 2011, VA did not receive a communication requesting a determination of entitlement or evidencing a belief in entitlement to compensation for a respiratory condition. 3. The evidence of record indicates that, for the entire claim period, the Veteran's respiratory problems with unspecified dyspnea were treated with inhalational anti-inflammatory medication. However, the record does not indicate that the Veteran's respiratory condition required at least monthly visits to a physician for required care or exacerbations or intermittent (at least three per year) courses of system (oral or parenteral) corticosteroids during the claim period. Lastly, the record does not demonstrate that the Veteran's respiratory condition resulted in a Forced Expiratory Volume in the First Second (FEV-1) of 40- to 55-percent predicted; or resulted in a FEV-1/Forced Vital Capacity (FVC) of 40 to 55 percent during pulmonary function testing (PFTs) at any point during the claim period. CONCLUSIONS OF LAW 1. The criteria for additional compensation for Al. C. as a dependent of the Veteran beyond February 1, 2008 are not met. 38 U.S.C. §§ 101(4), 1115, 5107, 5110; 38 C.F.R. §§ 3.4, 3.57, 3.102, 3.204, 3.206, 3.209, 3.210, 3.400, 3.401. 2. The criteria for an effective date prior to June 15, 2011 for the award of service connection for respiratory problems with unspecified dyspnea are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400(b)(2). 3. The criteria for an initial rating of 30 percent, but no higher, for respiratory problems with unspecified dyspnea are met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.27, 4.96, 4.97, Diagnostic Code (DC) 6602. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1989 to October 1993 and from February 2003 to May 2004, including service in Southwest Asia. These matters are before the Board of Veterans' Appeals (Board) on appeal from October 2013, January 2016, April 2016, and February 2019 decisions of the Department of Veterans Affairs (VA) Regional Offices (ROs). In his November 2018 and February 2020 substantive appeals, the Veteran requested a Board hearing. VA scheduled the Veteran for his requested hearing in September 2020. However, in August 2020, the Veteran withdrew his hearing request. Additional Compensation for Al. C. as a Dependent Beyond February 1, 2008 In January 2016, VA issued the Veteran a notification letter informing him that it had made a decision regarding his claim for entitlement to additional benefits for dependents received in October 2013. Firstly, VA added the Veteran's biological child C. to his compensation award effective November 1, 2013the first month following C.'s birth. Next, VA informed the Veteran that his stepchild Al. C. was removed from his award as a dependent effective February 1, 2008. In explaining Al. C.'s removal, VA stated that February 1, 2008 was the first day of the month following the Veteran's divorce from his prior spouse S., Al. C.'s biological mother. After reviewing the evidence of record, the Board finds that continued additional compensation for Al. C. as a dependent beyond February 1, 2008 is not warranted. Accordingly, the Board denies the Veteran's claim. In support of this determination, the Board first notes that the law provides for the rates of disability compensation and for payment of additional compensation for dependents of veterans who are at least 30 percent disabled. 38 U.S.C. §§ 1114(c), 1115, 1134, 1135. As indicated above in the Findings of Fact section, the Veteran has been in receipt of at least a 30 percent rating since July 1999. Accordingly, the Board finds that the Veteran has satisfied the initial eligibility requirement regarding additional compensation for dependents for the entire period relevant to his appeal. Next, the Board notes that awards of additional compensation for dependents are effective the latest of the following dates: (1) date of claim; (2) date dependency arises; (3) effective date of the qualifying disability rating provided evidence of dependency is received within one year of notification of such rating; or (4) date of commencement of Veteran's award. 38 C.F.R. § 3.401(b). The "date of claim" for additional compensation for dependents is the date of the veteran's marriage or birth/adoption of a child, if evidence of the event is received within a year of the event; otherwise, the date notice is received of the dependent's existence, if evidence is received within a year of VA's request. 38 C.F.R. § 3.401(b)(1). In the instant case, in July 2000, the Veteran informed VA that he had married S. earlier that month. In a VA Form 21-686c, Declaration of Status of Dependents, received in July 2000, the Veteran indicated that Al. C. was his only unmarried child under the age of 18. The Veteran did not specify whether Al. C. was his biological child, stepchild, or adopted child. With his July 2000 VA Form 21-686c, the Veteran enclosed a copy of Al. C.'s Social Security card and a birth certificate provided by the Iowa Methodist Medical Center. The birth certificate indicated that S. gave birth to Al. C. on January 17, 1991. Information pertaining to Al. C.'s biological father was left blank. On August 2000, VA sent the Veteran a letter informing him that it had amended his compensation award to include additional amounts for his dependent spouse S. and his dependent child Al. C. The letter also indicated that his compensation would decrease effective January 17, 2009, which is the day Al. C. turned 18 years old and would be removed as a dependent. Thereafter, in March 2008, the Veteran spoke with a VA employee over the telephone concerning his dependents. The Veteran advised that he had divorced S. on January 31, 2008, and that he would remarry a new spouse on April 19, 2008. This conversation was summarized in a March 2000 VA Form 119, Report of Contact, associated with the Veteran's claims file. Subsequently, in May 2008, the Veteran filed a new VA Form 21-686c. On this form, he indicated that he had divorced S. in Des Moines, Iowa on January 31, 2008. He then stated that he was currently married to O., whom he married in Kiev, Ukraine on April 19, 2008. On this VA Form 21-686c, the Veteran did not report any unmarried children. Pursuant to 38 C.F.R. § 3.57, and the underlying statutory provision 38 U.S.C. § 101(4), the term "child" is defined for VA purposes as (1) an unmarried person who is a legitimate child, (2) a child legally adopted before the age of 18, (3) a stepchild who acquired that status before the age of 18 and who is a member of the veteran's household or was a member of the veteran's household at the time of the veteran's death, or (4) an illegitimate child and: (A) is under the age of 18 years; or (B) before reaching the age of 18, became permanently incapable of self-support; or (C) is between the age of 18 and 23 and is pursuing a course of instruction at an educational institution approved by VA. See 38 C.F.R. § 3.57 (a)(1). In this case, the record indicates that Al. C. was the Veteran's stepchild until January 31, 2008, when he divorced her mother S. Since the January 31, 2008 divorce, Al. C. is ineligible to be a dependent on the Veteran's compensation award as the divorce severed their parent-stepchild relationship for VA purposes. See 38 C.F.R. § 3.210(d). Although this relationship was severed via the Veteran's divorce from S. on January 31, 2008, Al. C. may still be considered a dependent for compensation purposes if (1) the Veteran adopted her prior to her 18th birthday, or (2) sufficient evidence was submitted indicating that he was indeed Al. C.'s biological father despite the lack of information provided on Al. C.'s birth certificate. See 38 C.F.R. §§ 3.57(a)(1), 3.210(b). In this regard, the Board finds that the Veteran's claims file does not contain any documentation that Al. C. was adopted by the Veteran prior to her 18th birthday. The Veteran does not contend that he formally adopted Al. C. and has not referred to her as his adopted child. In regard to whether sufficient evidence was submitted indicating that the Veteran was indeed Al. C.'s biological father despite the lack of information provided on Al. C.'s birth certificate, the Board notes that 38 C.F.R. § 3.210(b) provides several avenues for a father to prove a relationship to a child when said individual is not noted as the child's father on the child's birth certificate. Specifically, proof of relationship may be established by: (1) An acknowledgement in writing signed by the individual in question; or (2) Evidence that the individual in question has been identified as the child's father by a judicial decree ordering him to contribute to the child's support or for other purposes; or (3) Any other secondary evidence which reasonably supports a finding of relationship, as determined by an official authorized to approve such findings, such as: (i) A copy of the public record of birth or church record of baptism, showing that the individual in question was the informant and was named as parent of the child; or (ii) Statements of persons who know that the individual accepted the child as his; or (iii) Information obtained from service department or public records, such as school or welfare agencies, which shows that with his knowledge the individual was named as the father of the child. Proof of relationship consistent with 38 C.F.R. § 3.210(b) is not contained in the Veteran's claims file. There is no evidence demonstrating that the Veteran adopted Al. C. prior to her 18th birthday or that he is the biological father of Al. C. In sum, Al. C. was the Veteran's stepchild during his marriage to S.; the Veteran divorced S. (Al. C.'s mother) on January 31, 2008; and the record does not contain evidence that the Veteran adopted Al. C. or that he is in fact her biological father. Accordingly, the Board concludes that the Agency of Original Jurisdiction (AOJ) did not err in removing Al. C. as a dependent child effective February 1, 2008the first day of the first month following the Veteran's divorce from S., Al. C.'s biological mother. See 38 C.F.R. § 3.31. Entitlement to additional compensation for Al. C. beyond February 1, 2008 as a dependent of the Veteran is denied. Earlier Effective Date for the Award of Service Connection for Respiratory Problems with Unspecified Dyspnea After reviewing the evidence of record, the Board finds that June 15, 2011 is the appropriate effective date for the award of service connection for respiratory problems with unspecified dyspnea. Accordingly, the Board denies the Veteran's claim for an earlier effective date for his service-connected respiratory problems with unspecified dyspnea. In support of this determination, the Board notes that, in January 2000, the Veteran filed his initial claim for service connection for a respiratory condition. In an August 2002 rating decision, a VA RO denied this issue. In explaining its denial, the RO indicated that the Veteran did not report to a VA examination scheduled in July 2002. Later in August 2002, the Veteran requested that his examination be rescheduled. Thereafter, in December 2002, the Veteran attended his rescheduled VA respiratory examination. Following this examination, and the completion of additional development, a VA RO issued a rating decision notification letter in July 2003 continuing its denial of service connection for a respiratory condition. The Veteran neither appealed this decision nor submitted any evidence within one year of notification. Accordingly, the July 2003 rating decision became final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 19.52; see also Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). As the July 2003 rating decision was final, the receipt of new and material evidence became necessary to reopen the issue and consider it once again on its merits. See 38 C.F.R. § 3.156(a). Since the issuance of the July 2003 rating decision, VA did not receive any communication requesting entitlement to service connection for a respiratory condition until June 15, 2011. Under 38 C.F.R. § 3.400(r), the effective date for an award of a compensation based upon a reopened claim is the date of receipt of claim or date entitlement arose, whichever is later. Here, following receipt of the Veteran's June 15, 2011, a VA RO reopened the Veteran's claim in a January 2012 rating decision as it determined new and material evidence had been received. Although the January 2012 rating decision denied service connection on the merits, the issue remained open and pending until, via an April 2016 rating decision, VA granted the Veteran service connection for respiratory problems with unspecified dyspnea. In granting service connection, the VA RO assigned June 15, 2011 as the effective date for the award. June 15, 2011 is the date of receipt of the Veteran's application to reopen his claim for entitlement to service connection for a respiratory condition. As June 15, 2011 is the earliest effective date permissible under 38 C.F.R. § 3.400(r), the Board must deny the Veteran's claim for an effective date prior to June 15, 2011. Higher Initial Rating for Respiratory Problems with Unspecified Dyspnea The Veteran seeks entitlement to an initial rating in excess of 10 percent for his service-connected respiratory problems with unspecified dyspnea. See June 2016 notice of disagreement; November 2018 VA Form 9. The Board finds that the Veteran is entitled to an initial rating of 30 percent, but no higher, for his service-connected respiratory problems with unspecified dyspnea. The Veteran's respiratory disability is currently assigned a 10 percent rating pursuant to 38 C.F.R. § 4.97, DC 6602. Under DC 6602, a 10 percent rating is assigned when the disability at issue requires intermittent inhalational or oral bronchodilator therapy. Alternatively, a 10 percent rating may also be assigned when the performance of PFTs produces of results of a FEV-1 of 71 to 80 percent predicted or a FEV-1/FVC of 71 to 80 percent predicted. See 38 C.F.R. § 4.97, DC 6602. A 30 percent rating is assigned when the disability at issue: (1) requires daily inhalational or oral bronchodilator therapy; (2) requires inhalational anti-inflammatory medication; or (3) when the performance of PFTs produces results of a FEV-1 of 56 to 70 percent predicted, or a FEV-1/FVC of 56 to 70 percent. Id. A 60 percent rating requires evidence of one of the following: (1) PFTs results of a FEV-1 of 40 to 55 percent predicted, or a FEV-1/FVC of 40 to 55 percent; (2) at least monthly visits to a physician for required care of exacerbations; or (3) intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. Id. The Veteran was provided two VA respiratory examinations during the claim period. At the December 2011 VA examination, the Veteran described symptoms of hemoptysis, cough with purulent sputum, and orthopnea to a VA examiner. The Veteran then stated that he did not have any episodes of respiratory failure requiring respiration assistance from a machine, and that he did not currently receive any active treatment for his respiratory symptoms. The Veteran responded negatively when asked if his condition required the use of outpatient oxygen therapy. The December 2011 VA examiner conducted pulmonary function tests (PFTs) which produced a pre-bronchodilator result of FVC 101 percent predicted. The examiner then noted that FEV-1/FVC was not available and that post-bronchodilator results were not performed because pre-bronchodilator results were within normal limits. Lastly, the examiner remarked that there was no discrepancy between the PFT results and the clinical examination of the Veteran. Thereafter, VA provided the Veteran another VA respiratory examination in November 2015. On this occasion, the Veteran reported symptoms of frequent and chronic cough and worsening dyspnea. The examiner noted that the Veteran's respiratory condition did not require the use of oral or parenteral corticosteroid medications, oral bronchodilators, antibiotics, or outpatient oxygen therapy. However, the examiner did indicate that the Veteran's condition required the intermittent use of inhalational bronchodilators and inhalational anti-inflammatory medication. In addition, the examiner noted that the Veteran reported relatively poor responses to empiric use of a metered dose inhaler (MDI), albuterol, and Symbicort. Lastly, the examiner conducted PFTs which produced post-bronchodilator results of (1) a FEV-1 of 86 percent predicted, and (2) FEV-1/FVC of 87 percent. In addition to the findings recorded in the above-described VA examination reports, the Board notes that a June 2015 VA pulmonary consultation noted the results of four PFTs conducted between September 2011 and January 2015. In September 2011, the Veteran produced a FEV-1 of 97 percent predicted and a FEV-1/FVC of 88 percent. In June 2013, the Veteran produced a FEV-1 of 91 percent predicted and a FEV-1/FVC of 86 percent. In April 2014, the Veteran produced a FEV-1 of 69 percent predicted and a FEV-1/FVC of 79 percent. Lastly, in January the Veteran produced a FEV-1 of 102 percent predicted and a FEV-1/FVC of 95 percent. Further, the VA treatment records associated with the Veteran's claims file documented that the Veteran had been prescribed albuterol and Symbicort since at least 2013. See, e.g., December 2013 VA Primary Care Note; July 2013 VA Pulmonary Consultation. Considering the above evidence of record, the Board concludes that the criteria for the assignment of an increased 30 percent rating under DC 6602 are met. The Board bases this conclusion upon the Veteran's long-term prescriptions of albuterol and Symbicort, his April 2014 PFTs producing a FEV-1 of 69 percent predicted, and November 2015 VA examiner's notation that the Veteran's condition required the intermittent use of inhalational anti-inflammatory medication. As such, a 30 percent rating is granted pursuant to DC 6602. However, the Board concludes that entitlement to the next higher rating of 60 percent is not warranted under DC 6602. Specifically, during the relevant appeal period, the Veteran did not produce results of a FEV-1 of 40 to 55 percent predicted or a FEV-1/FVC of 40 to 55 percent during any PFTs. Additionally, the evidence of record does not demonstrate that the Veteran visited physicians at least once a month for care of his respiratory condition during the claim period. Rather, the Veteran only sought intermittent care intermittently and not monthly. Indeed, the December 2011 VA examiner remarked that the Veteran was not under active treatment for his condition. Lastly, the record does not indicate that the Veteran received intermittent oral or parenteral corticosteroids for his respiratory condition during the claim period. While the Board notes that Symbicort contains a corticosteroid, this medication was inhaled. DC 6602 specifies that, for the assignment of a 60 percent rating, the evidence must demonstrate the intermittent use of oral or parenteral corticosteroids. See 38 C.F.R. § 4.97. Thus, the Board concludes that the Veteran's Symbicort use does not satisfy the criteria for a 60 percent rating under Diagnostic Code 6602. Accordingly, the Board finds that entitlement to an initial rating of 30 percent, but no higher, for respiratory problems with unspecified dyspnea is warranted. REASONS FOR REMAND 1. Service Connection for a Heart Condition The Veteran contends that he has a current heart condition that is secondary to his currently service-connected respiratory condition and/or MDD. See November 2018 Veteran's Supplemental Claim. In December 2018, the Veteran was provided a VA examination and medical opinion concerning the etiology of his current heart condition. However, the Board finds the December 2018 opinion to be inadequate for adjudicative purposes. Although the examiner opined that the Veteran's heart condition was less likely than not proximately due to or the result of the Veteran's respiratory problems with unspecified dyspnea, the opinion did not address whether the Veteran's current respiratory condition was aggravated by his service-connected respiratory condition. Further, the Board finds the examiner did not provide sufficient rationale for his opinion on causation and that the opinion is conclusory. Thus, the Board finds that remand for a new VA medical opinion is warranted to address whether the Veteran's heart condition is secondary to his service-connected respiratory problems with unspecified dyspnea. Further, there is no VA medical opinion addressing whether the Veteran's heart condition was caused or aggravated by his service-connected MDD. In light of the Veteran's contention that his heart condition is secondary to his service-connected MDD, the VA medical opinion must also address this theory of entitlement. 2. Increased Rating for MDD As an initial matter, the Board notes that, in two separate October 2018 Statement of the Cases (SOCs), the RO adjudicated the issues of 1) entitlement to a disability rating in excess of 30 percent for MDD prior to November 10, 2015, 2) entitlement to an effective date prior to November 10, 2015 for the grant of a 50 percent evaluation for MDD, and 3) entitlement to a disability rating in excess of 50 percent for MDD. Although they were listed as three separate issues in the October 2018 SOCs, these appeals all stem from the Veteran's May 2012 claim and October 2013 rating decision on the issue entitlement to an increased rating for MDD. The issue of entitlement to an effective date prior to November 10, 2015 is duplicative of the simultaneously-appealed MDD increased rating issue, which dates back to the May 2012 claim. As the increase to 50 percent for MDD from November 10, 2015 represents only a partial grant of benefits, the issue of entitlement to an increased rating for MDD remains pending on appeal before the Board from the May 2012 claim. AB v. Brown, 6 Vet. See App. 35, 38 (1993). Accordingly, the Board has recharacterized these issues as entitlement to a disability rating greater than 30 percent prior to November 10, 2015, and greater than 50 percent thereafter, for MDD, as noted on the first page of this decision. Moving to the merits of the Veteran's MDD increased rating claim, the Veteran was most recently provided a VA examination concerning his psychiatric impairment in November 2015. During an October 2018 VA cardiology consultation, the Veteran reported that his mental health issues were "somewhat worse" and that his medications were readjusted. See October 2018 VA treatment record. In light of the evidence that the Veteran's MDD has worsened since his most recent VA examination in November 2015, the Board finds that remand is warranted to obtain an updated VA examination. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991) (indicating that where the evidence of record does not reflect the current state of a disability, a new VA examination must be conducted). 3. TDIU In May 2012, the Veteran contended that he was having difficulty maintaining a full-time job due to his service-connected disabilities. See May 2012 Correspondence. As such, the Board finds that the issue of entitlement to a TDIU has been raised as part and parcel of the Veteran's claim for entitlement to an increased rating for MDD. Accordingly, the Board has added entitlement to a TDIU as an issue currently on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). However, as entitlement to a TDIU is intertwined with the remanded claim of entitlement to an increased rating for MDD, a determination on the merits would be premature at this time. Accordingly, entitlement to a TDIU must also be remanded. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records and associate them with the claims file. Specifically, obtain any VA treatment records since November 2019. 2. After item (1) has been completed to the extent possible, send the Veteran's claims file to an appropriate VA clinician for the issuance of a medical opinion regarding the nature and etiology of his current heart condition. After reviewing the claims file, the clinician must address the following: (a.) Please state whether it is at least as likely as not (the favorable and unfavorable evidence is in approximate balance or is nearly equal) that any of the Veteran's heart conditions had its onset in, was caused by, or is otherwise related to service. (b.) Please state whether it is at least as likely as not (the favorable and unfavorable evidence is in approximate balance or is nearly equal) that the Veteran's current heart condition was caused by his service-connected respiratory condition. (c.) Please state whether it is at least as likely as not (the favorable and unfavorable evidence is in approximate balance or is nearly equal) that the Veteran's current heart condition was aggravated (worsened beyond natural progression) by his service-connected respiratory condition. (d.) Please state whether it is at least as likely as not (the favorable and unfavorable evidence is in approximate balance or is nearly equal) that the Veteran's current heart condition was caused by his service-connected MDD. (e.) Please state whether it is at least as likely as not (the favorable and unfavorable evidence is in approximate balance or is nearly equal) that the Veteran's current heart condition was aggravated (worsened beyond natural progression) by his service-connected MDD. In providing responses for parts (a) through (e), please provide separate explanatory rationales for causation and aggravation. The clinician should consider medical and lay evidence dated both prior to and since the filing of the claim. The clinician must provide a complete rationale for any opinion rendered. If the clinician cannot provide an opinion without resorting to speculation, he or she should explain why an opinion cannot be provided (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). 3. After items (1) has been completed to the extent possible, schedule the Veteran for a VA examination with an appropriate clinician to determine the current nature and severity of his service-connected MDD. The entire claims file, including a copy of this remand, must be made available to the examiner for review. The examination should be conducted in accordance with the current examination worksheet or disability benefits questionnaire (DBQ). To the extent possible, the examiner should comment upon the functional effects of the Veteran's MDD. The examiner should describe the limitations and restrictions imposed by the service-connected MDD on routine work activities, such as interacting with customers/coworkers, understanding and remembering instructions, and using technology, plus other physical activities. The examiner must consider all medical and lay evidence of record when providing any opinion in conjunction with the examination. Specifically, the examiner must consider the Veteran's October 2018 report that his mental health issues were "somewhat worse" and that his medications were readjusted. See October 2018 VA treatment record. All opinions must be accompanied by complete rationale. If the examiner cannot provide an opinion without resorting to speculation, he or she should explain why an opinion cannot be provided (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). C. Samuelson Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N.S. Pettine, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.